Notice of Privacy Practices

JOINT NOTICE OF PRIVACY PRACTICES AND

NOTICE OF ORGANIZED HEALTH CARE ARRANGEMENT

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this Notice please contact our “Privacy Contact” 714-845-8605.

We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services or payment of health care services.

This Notice was published and became effective on November 18, 2015. We are required to abide by the terms of this Notice currently in effect. We may change the terms of this Notice at any time. The new Notice will be effective for all protected health information that we maintain at that time. You may obtain a copy of any revised Notice by accessing our website, calling our Privacy Contact and requesting that a revised copy be sent to you in the mail, or asking for one at the time of your next appointment.

Organized Health Care Arrangement: Pacific Dental Services, LLC (“PDS”) provides business support services to a number of entities engaged in the practice of dentistry (“Dental Entities”). All of the Dental Entities are included in the Smile Generation website maintained by PDS, and the dental office locations operated by the Dental Entities are listed at the following url: http://www.smilegeneration.com/SiteMap.aspx, as updated from time to time. PDS, its subsidiaries and the Dental Entities are participants in an Organized Health Care Arrangement for purposes of federal privacy requirements and, accordingly, they may share information about you with each other for treatment, payment, and operations purposes as described in this Notice. As used in this Notice, the words “we,” “our” and “us” collectively refer to PDS, its subsidiaries and the Dental Entities.

1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION. Uses and Disclosures of Protected Health Information for Treatment, Payment, or Operations - We may use or disclose your protected health information for treatment, payment and health care operations as described in this Section 1 without authorization from you. Your protected health information may be used and disclosed by your dentist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the dentist’s practice.

Following are the types and examples of uses and disclosures of your protected health care information that the dentist’s office is permitted to make without your specific authorization. These descriptions and examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office. In general, information regarding dental services we provide may be used and disclosed as provided below, but patients in some states may find that other types of protected health information are subject to additional rules under state law, as described in the table at the end of this Notice.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party, consultations with another dentist, or your referral to another dentist for your diagnosis and treatment. For example, a dentist treating you may need to know if you have other health problems that might complicate your treatment and therefore may request your medical record from another health care provider that has provided treatment to you.

Payment: Your protected health information may be used to obtain or provide payment for your dental services, including disclosures to other entities. This may include certain activities that your health insurance plan may undertake before it approves or pays for the services we recommend for you such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you, and undertaking utilization review activities. For example, we may need to give your insurance company information about dental surgery you received so your insurance will pay for the care.

Operations: We may use or disclose your protected health information in order to support the business activities of your dentist’s practice. These activities include, but are not limited to: quality assessment and improvement activities; reviewing the competence or qualifications of professionals; securing stop-loss or excess of loss insurance; obtaining legal services or conducting compliance programs or auditing functions; business planning and development; business management and general administrative activities, such as compliance with the Health Insurance Portability and Accountability Act; resolution of internal grievances; due diligence in connection with the sale or transfer of assets of your dentist’s practice; creating de-identified health information; and conducting or arranging for other business activities. For example, we may use your dental information to evaluate the performance of our dentists and staff in providing care to you. In addition, we may disclose your protected health information to another provider, health plan, or health care clearinghouse for limited operational purposes of the recipient, as long as the other entity has, or has had, a relationship with you. Such disclosures will be limited to certain purposes, including: quality assessment and improvement activities, population-based activities relating to improving health or reducing health care costs, case management, conducting training programs, accreditation, certification, licensing, credentialing activities, and health care fraud and abuse detection and

Business Associates: We may share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services, accounting services, legal services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

Treatment Alternatives and Health-Related Products and Services: We may use or disclose your protected health information, as necessary, to provide you with information about a product or service to encourage you to purchase or use the product or services for the following limited purposes: (1) to describe our participation in a dentist network or health plan network, or to describe if, and the extent to which, a product or service (or payment for such product or service) is provided by our practice or included in a plan of benefits; (2) for your treatment; or (3) for your case management or care coordination, or to direct or recommend alternative treatments, therapies, dentists, or settings of care.

Family and Friends: We may provide your protected health information to individuals, such as family and friends, who are involved in your care or who help pay for your care. We may do this if you tell us we can do so, or if you know we are sharing your protected health information with these people and you do not object. There may also be circumstances when we can assume, based on our professional judgment, that you would not object. For example, we may assume you agree to our disclosure of your information to your spouse if your spouse comes with you into the exam room. Also, if you are not able to approve or object to a disclosure, we may make disclosures to a particular individual (such as a family member or friend), that we feel are in your best interest and that relate to that person’s involvement in your care or payment of your care. For example, we may make a professional judgment about your best interests that allow another person to pick up such things as prescriptions, dental supplies and X-rays.

2.OTHER PERMITTED USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION. We may use or disclose your protected health information without your permission in the following circumstances, subject to all applicable legal requirements

As Required By Law: As required by federal, state, or local law.

Public Health Activities: To a public health authority for public health activities including the following: to prevent or control disease, injury or disability; or to report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.

Health Oversight Activities: To a health oversight agency for audits, investigations, inspections, licensing purposes, or as necessary for certain government agencies to monitor the health care system, government programs, and compliance with civil rights

Lawsuits and Disputes: In response to a subpoena or a court or administrative order, if you are involved in a lawsuit or a dispute, or in response to a court order, subpoena, warrant, summons or similar process, if asked to do so by law enforcement.

Law Enforcement: To law enforcement for law enforcement purposes, so long as applicable legal requirements are met.

Coroners, Medical Examiners and Funeral Directors: To a coroner or medical examiner, (as necessary, for example, to identify a deceased person or determine the cause of death) or to a funeral director, as necessary to allow him/her to carry out his/her activities.

Organ and Tissue Donation: If you are an organ or tissue donor, to organizations that handle organ procurement or organ, eye or transplantation, or to an organ donation bank, as necessary to facilitate a donation and transplantation.

Research: For research purposes under certain limited circumstances. Research projects are subject to a special approval process. Therefore, we will not use or disclose your protected health information for research purposes until the particular research project has been approved through this special approval process.

Serious Threat to Health or Safety; Disaster Relief: To appropriate individual(s)/organization(s) when necessary (i) to prevent a serious threat to your health and safety or that of the public or another person, or (ii) to identify, locate, or notify your family members or persons responsible for you in a disaster relief effort.

Military and Veterans: As required by military command or other government authority for information about a member of the domestic or foreign armed forces, if you are a member of the armed forces.

National Security; Intelligence Activities; Protective Service: To federal officials for intelligence, counterintelligence, and other national security activities authorized by law, including activities related to the protection of the President, other authorized persons or foreign heads of state, or related to the conduct of special investigations.

Workers’ Compensation: For workers’ compensation or similar work-related injury programs, to the extent required by law.

Inmates: To a correctional institution (if you are an inmate) or a law enforcement official (if you are in that official’s custody) as necessary (i) for the institution to provide you with health care; (ii) to protect your or others’ health and safety; or (iii) for the safety and security of the correctional institution.

3. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOUR WRITTEN AUTHORIZATION. All other uses and disclosures of your protected health information not covered by this Notice will be made only with your written authorization. We would seek your authorization, for example, if we wanted to use or disclose your health information for research or marketing purposes. In some situations, federal and state laws may require authorization from you before we can disclose specially protected health information. Examples of protected health information that may be subject to special protections include protected health information involving mental health, HIV/AIDS, reproductive health, sexually transmitted or other communicable diseases, and alcohol or drug abuse. We may limit disclosure of the specially protected health information to what the law permits or we may contact you for the necessary authorization.

You may revoke any authorization, at any time, by notifying, in writing, our Privacy Contact. If you revoke your authorization, we will no longer use or disclose your protected health information for the purpose you had previously approved, except to the extent that your dentist or the provider’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

4.YOUR RIGHTS. Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in your chart, including medical and billing records and any other records that your dentist and the practice use for making decisions about you. Requests to access your protected health information must be made in writing and submitted to our Privacy Contact. We may charge you for the cost of copying, mailing or associated supplies.

Under federal law, however, you may not inspect or copy certain records, including: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. You may make this request by submitting a written request to our Privacy Contact that states the specific restriction requested and to whom you want the restriction to apply.

Your dentist is not required to agree to a restriction that you may request, unless you request to restrict the disclosure of your protected health information to a health plan for the purpose of carrying out payment or health care operations and the protected health information relates only to a health care item or service for which you have paid us in full out of your pocket (not through insurance), in which case we will accept such restriction request. If your dentist does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with our Privacy Contact.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.

You may have the right to request an amendment to your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Contact to determine if you have questions about amending your medical record. You may request an amendment to your medical record by submitting a written request to our Privacy Contact.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. It also excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes, disclosures for which you have signed an authorization and certain other disclosures. You have the right to receive specific information regarding these disclosures that occurred after during the six years prior to the date of your request. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. To request an accounting of disclosures, submit a written request to our Privacy Contact.

You have the right to be informed of any unauthorized disclosures of your unsecured protected health information. This means that if we or our service providers improperly allow access to your unsecured health information in a way that compromises that information, we will provide you timely notice of that breach. You have the right to obtain a paper copy of this Notice from us, upon request, even if you have agreed to accept this Notice

5. COMPLAINTS. You may complain to us or to the Secretary of Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Contact of your complaint. We will not retaliate against you for filing a complaint. You may contact our Privacy Contact for further information about the complaint

6. FURTHER RESTRICTIONS. In some situations, federal and state laws may require authorization from you before we can disclose specially protected health information. Examples of protected health information that may be subject to special protections include protected health information involving mental health, HIV/AIDS, reproductive health, sexually transmitted or other communicable diseases, and alcohol or drug abuse. We may limit disclosure of the specially protected health information to what the law permits or we may contact you for the necessary authorization.

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*Regular value of at least $290. In absence of gum (periodontal) disease. New patients only. Cannot be combined with any other offers. Coupon must be presented at appointment. Limit 1 per patient. Subject to insurance restrictions; cannot be applied to insurance co-payments. Not valid for appointments with pediatric dentist.